carbon monoxide poisoning bryan bledsoe, do, facep

Carbon Monoxide PoisoningCarbon Monoxide Poisoning

Bryan Bledsoe, DO, FACEPBryan Bledsoe, DO, FACEP

Conflict of Interest StatementConflict of Interest Statement

Bryan E. Bledsoe, DO, FACEPMasimo (Consultant)

AMA and ACEP Faculty Disclosure completed and submitted.

Bryan E. Bledsoe, DO, FACEPMasimo (Consultant)

AMA and ACEP Faculty Disclosure completed and submitted.

Carbon MonoxideCarbon Monoxide

Significantly more is known about CO poisoning since Claude Bernard described it in 1857.

Bernard C. Lecons sur les Effets des Substaces Toxiques et Medicamenteuses. Paris: J-B Bailliere et Fils, 1857

Significantly more is known about CO poisoning since Claude Bernard described it in 1857.

Bernard C. Lecons sur les Effets des Substaces Toxiques et Medicamenteuses. Paris: J-B Bailliere et Fils, 1857

ChemistryChemistry

Gas

Odorless

Colorless

Tasteless

Relative vapor density = 0.97

Extremely stable

Extremely flammable

Gas

Odorless

Colorless

Tasteless

Relative vapor density = 0.97

Extremely stable

Extremely flammable

Sources of Carbon MonoxideSources of Carbon Monoxide

Endogenous

Exogenous

Methylene chloride

Endogenous

Exogenous

Methylene chloride


Endogenous:Normal heme catabolism:

Only biochemical reaction in the body known to produce CO.

Levels increased in:Hemolytic anemia.

Sepsis

Endogenous:Normal heme catabolism:

Only biochemical reaction in the body known to produce CO.

Levels increased in:Hemolytic anemia.

Sepsis


Exogenous:House fires.

Gas–powered electrical generators.

Automobile exhaust.

Propane-powered vehicles.

Heaters.

Camp stoves.

Boat exhaust.

Cigarette smoke.

Exogenous:House fires.

Gas–powered electrical generators.

Automobile exhaust.

Propane-powered vehicles.

Heaters.

Camp stoves.

Boat exhaust.

Cigarette smoke.


Methylene chloride:Paint and adhesive remover.

Converted to CO in the liver after inhalation.

Methylene chloride:Paint and adhesive remover.

Converted to CO in the liver after inhalation.

IncidenceIncidence

CO is leading cause of poisoning deaths in industrialized countries.

CO may be responsible for half of all poisonings worldwide.

~5,000–6,000 people die annually in the United States as a result of CO poisoning.

~40,000–50,000 emergency department visits annually result from CO poisoning.

CO is leading cause of poisoning deaths in industrialized countries.

CO may be responsible for half of all poisonings worldwide.

~5,000–6,000 people die annually in the United States as a result of CO poisoning.

~40,000–50,000 emergency department visits annually result from CO poisoning.

Source: Hampson NB. Trends in the incidence of carbon monoxide poisoning in the United States. Am J Emerg Med. 2005;23:838-841

IncidenceIncidence

Source: Hampson NB, Weaver LK. Carbon Monoxide Poisoning: A New Incidence of an Old Disease. Undersea Hyperb Med. 2007;34:163-168

IncidenceIncidence

CDC. MMWR. 56;50: December 21, 2007

•COHb not routinely measured in autopsy specimens.•Post-mortem measurements often unreliable

IncidenceIncidence

Accidental CO poisoning deaths declining:

Improved motor vehicle emission policies.

Use of catalytic converters.

Home CO detectors.

Accidental CO poisoning deaths declining:

Improved motor vehicle emission policies.

Use of catalytic converters.

Home CO detectors.

IncidenceIncidence

Most accidental deaths are due to:

House fires.Automobile exhaust.Indoor-heating systems.Stoves and other appliances.Gas-powered electrical generatorsCharcoal grills. Camp stoves.Water heaters.Boat exhausts.

Most accidental deaths are due to:

House fires.Automobile exhaust.Indoor-heating systems.Stoves and other appliances.Gas-powered electrical generatorsCharcoal grills. Camp stoves.Water heaters.Boat exhausts.

IncidenceIncidence

Increased accidental CO deaths:

Patient > 65 years of age.MaleEthanol intoxication.

Accidental deaths peak in winter:

Use of heating systems.Closed windows.

Increased accidental CO deaths:

Patient > 65 years of age.MaleEthanol intoxication.

Accidental deaths peak in winter:

Use of heating systems.Closed windows.

IncidenceIncidence

Significant increase in CO poisoning seen following disasters.

Primarily relates to loss of utilities and reliance on gasoline-powered generators and use of fuel-powered heaters.

Significant increase in CO poisoning seen following disasters.

Primarily relates to loss of utilities and reliance on gasoline-powered generators and use of fuel-powered heaters.

IncidenceIncidence

Fetal hemoglobin has a much greater affinity for CO than adult hemoglobin.Pregnant mothers may exhibit mild to moderate symptoms, yet the fetus may have devastating outcomes.

Fetal hemoglobin has a much greater affinity for CO than adult hemoglobin.Pregnant mothers may exhibit mild to moderate symptoms, yet the fetus may have devastating outcomes.

http://upload.wikimedia.org/wikipedia/en/f/f0/Hemoglobin_F.png

PathophysiologyPathophysiology

CO poisoning actually very complex.CO binds to hemoglobin with an affinity ~ 250 times that of oxygen.

CO poisoning actually very complex.CO binds to hemoglobin with an affinity ~ 250 times that of oxygen.


CO also binds to other iron-containing proteins:

MyoglobinCytochromeNeuroglobin

Binding to myoglobin reduces O2 available in the heart:

IschemiaDysrhythmiasCardiac dysfunction

CO also binds to other iron-containing proteins:

MyoglobinCytochromeNeuroglobin

Binding to myoglobin reduces O2 available in the heart:

IschemiaDysrhythmiasCardiac dysfunction


COHb ultimately removed from the circulation and destroyed.

Half-life:Room air: 240-360 minutes

O2 (100%): 80 minutes

Hyperbaric O2: 22 minutes

COHb ultimately removed from the circulation and destroyed.

Half-life:Room air: 240-360 minutes

O2 (100%): 80 minutes

Hyperbaric O2: 22 minutes


Signs and symptoms of CO poisoning do NOT correlate with COHb levels.

Other pathophysiologic processes must be involved.

Signs and symptoms of CO poisoning do NOT correlate with COHb levels.

Other pathophysiologic processes must be involved.


Nitric oxide (NO):Highly-reactive gas that participates in numerous biochemical reactions.

Oxygen free-radical

Levels increased with CO exposure.

Nitric oxide (NO):Highly-reactive gas that participates in numerous biochemical reactions.

Oxygen free-radical

Levels increased with CO exposure.

http://upload.wikimedia.org/wikipedia/commons/7/73/Nitric-oxide-3D-vdW.png


Nitric Oxide (NO):Causes cerebral vasodilation:

SyncopeHeadache

May lead to oxidative damage to the brain:

Probable cause of syndrome of delayed neurologic sequelae (DNS).Associated with reperfusion injury.

Nitric Oxide (NO):Causes cerebral vasodilation:

SyncopeHeadache

May lead to oxidative damage to the brain:

Probable cause of syndrome of delayed neurologic sequelae (DNS).Associated with reperfusion injury.

CO ExposureCO Exposure


15 year (1980-1994) comparison of atmospheric CO levels and mortality in Toronto.

Adjusted for day-of-the week effects, nonparametric smoothed functions of the day of the study, and weather variables.

15 year (1980-1994) comparison of atmospheric CO levels and mortality in Toronto.

Adjusted for day-of-the week effects, nonparametric smoothed functions of the day of the study, and weather variables.


Carbon Monoxide (ppm)—2 day Average


NO2

Total Suspended Particulates

CO

O3

SO2 SO4


“Epidemiological data indicate a potent and pervasive effect of even low ambient CO levels.”

“Epidemiological data indicate a potent and pervasive effect of even low ambient CO levels.”

Source: Burkett RT, Cakmak S, Raizenne ME, et al. The Association between Ambient Carbon Monoxide Levels and Daily Mortality in Toronto, Canada. J Air Waste Mgmt. 1998;48:689-700


Swedish study.

Population-based cohort study of 22,444 men between 1974-1984.

COHb% was measured from 6/77 to 1/81 in 8,413 men (ages 34-49 years).

Men with history of MI, cancer and/or stroke were excluded.

Swedish study.

Population-based cohort study of 22,444 men between 1974-1984.

COHb% was measured from 6/77 to 1/81 in 8,413 men (ages 34-49 years).

Men with history of MI, cancer and/or stroke were excluded.


Cohort analysis:Never smokers: 2,893

Divided into 4 quartiles based upon COHb%:COHb% = 0.43 (0.13-0.49) [N= 743 men]

COHb% = 0.54 (0.50-0.57) [N= 781 men]

COHb% = 0.62 (0.58-0.66) [N= 653 men]

COHb% = 0.91 (0.67-5.47) [N= 716 men]

Cohort analysis:Never smokers: 2,893

Divided into 4 quartiles based upon COHb%:COHb% = 0.43 (0.13-0.49) [N= 743 men]

COHb% = 0.54 (0.50-0.57) [N= 781 men]

COHb% = 0.62 (0.58-0.66) [N= 653 men]

COHb% = 0.91 (0.67-5.47) [N= 716 men]


Cardiac Event CVD Deaths All Deaths

Variable RR 95% CI RR 95% CI RR 95% CI

First Quartile Reference Reference Reference

Second Quartile 1.20 0.59-2.46 0.80 0.30-2.16 1.01 0.60-1.72

Third Quartile 1.73 0.87-3.46 1.11 0.43-2.88 1.09 0.63-1.87

Fourth Quartile 3.37 1.84-6.18 3.50 1.62-7.27 2.50 1.61-3.90

RR = Relative Risk is the risk of an event (or of developing a disease) relative to exposure. Relative risk is a ratio of the probability of the event occurring in the exposed group versus the control (non-exposed) group.


“Incidence of CV disease and death in non-smokers was related to COHb%. It is suggested that measurements of COHb% could be a part of risk assessment in the non-smoking patients considered at risk of cardiac disease.”

“Incidence of CV disease and death in non-smokers was related to COHb%. It is suggested that measurements of COHb% could be a part of risk assessment in the non-smoking patients considered at risk of cardiac disease.”

Source: Hedblad B, Engström, Janzon E, Berglunf G, Janzon L. COHb% as a marker of cardiovascular risk in never smokers: Results from a population-based cohort study. Scand J Pub Health. 2006;34:609-615


Inhaled CO may interrupt myocardial oxidative phosphorylation by decreasing the activity of myocardial cytochrome oxidase (CcOX), the terminal oxidase in the electron transport chain.

Animal study (mice) exposed to 1,000 ppm CO over 3 hours.

Inhaled CO may interrupt myocardial oxidative phosphorylation by decreasing the activity of myocardial cytochrome oxidase (CcOX), the terminal oxidase in the electron transport chain.

Animal study (mice) exposed to 1,000 ppm CO over 3 hours.


Virtually identical to the effect of cyanide.Virtually identical to the effect of cyanide.


1. CO decreased myocardial CcOX activity.

2. CO exposure decreases heme aa3 content.

3. CO decreases steady-state levels of CcOX subunit I protein without affecting steady state mRNA levels (increased enzyme destruction).

4. CO exposure (1,000 ppm) increases COHb levels without causing tissue hypoxia.

1. CO decreased myocardial CcOX activity.

2. CO exposure decreases heme aa3 content.

3. CO decreases steady-state levels of CcOX subunit I protein without affecting steady state mRNA levels (increased enzyme destruction).

4. CO exposure (1,000 ppm) increases COHb levels without causing tissue hypoxia.


Cause:Increased enzyme destruction due to binding of CO to heme groups.

Production of reactive oxygen species production, oxidative stress, and subsequent protein destruction.

Cause:Increased enzyme destruction due to binding of CO to heme groups.

Production of reactive oxygen species production, oxidative stress, and subsequent protein destruction.

Source: Iheagwara KN, Thom SR, Deutschman CS, Levy RJ. Myocardial cytochrome oxidase activity is decreased following carbon monoxide exposure. Biochem Biophys Acta. 2007;1772:1112-1116


Ex Vivo murine model.

Grouping:100% O2 + KHH (Control Group)

70% O2 + 30% N2 + KHH (N2 Control Group)

70% O2 + 30% CO + KHH (CO Group)

Parameters:LVEsP

LVEdP

Coronary Perfusion Pressure

* - KHH is a buffer solution used as a perfusate.

Ex Vivo murine model.

Grouping:100% O2 + KHH (Control Group)

70% O2 + 30% N2 + KHH (N2 Control Group)

70% O2 + 30% CO + KHH (CO Group)

Parameters:LVEsP

LVEdP

Coronary Perfusion Pressure

* - KHH is a buffer solution used as a perfusate.


Conclusions:COHb not a factor (not in perfusate).

Binding of CO to myoglobin, cytochrome oxidase, and other intracellular enzyme systems is the most likely explanation.

Conclusions:COHb not a factor (not in perfusate).

Binding of CO to myoglobin, cytochrome oxidase, and other intracellular enzyme systems is the most likely explanation.

Source: Suner S, Jay S. Carbon monoxide has direct toxicity on the myocardium distinct from effects of hypoxia in an ex vivo rat heart model. Acad Emerg Med. 2008;15:59-65


Chemical Molar Mass(g/mol)

Water Solubility(mL/100 mL)

CO 28.01 2.3

NO 30.01 7.4

HCN 27.03 Completely Miscible

• CO and NO are known second messengers• CO, NO and CN- bind to heme and competitively inhibit CcOX.• NO targets intracellular heme.• NO impairs heme synthesis and enhances heme destruction by increasing heme oxygenase activity.

Basic ScienceBasic Science

Free radical (reactive oxygen species):Highly-reactive atom, molecule or molecular fragment with a free or unpaired electron.

Produced in various ways such as normal metabolic processes, ultraviolet radiation from the sun, and nuclear radiation.

Free radicals have been implicated in aging, cancer, cardiovascular disease and other kinds of damage to the body.

Every cell in the body suffers approximately 10,000 free radical hits a day.

Free radical (reactive oxygen species):Highly-reactive atom, molecule or molecular fragment with a free or unpaired electron.

Produced in various ways such as normal metabolic processes, ultraviolet radiation from the sun, and nuclear radiation.

Free radicals have been implicated in aging, cancer, cardiovascular disease and other kinds of damage to the body.

Every cell in the body suffers approximately 10,000 free radical hits a day.


Free radicals:Most clinically-significant free radicals in medicine are:

Superoxide free radical (O2-)

Hydrogen peroxide (H2O2)

Hydroxyl free radical (OH)

Nitric oxide (NO)

Singlet oxygen (1O2)

Ozone (O3)

Free radicals:Most clinically-significant free radicals in medicine are:

Superoxide free radical (O2-)

Hydrogen peroxide (H2O2)

Hydroxyl free radical (OH)

Nitric oxide (NO)

Singlet oxygen (1O2)

Ozone (O3)


Various enzyme systems are available to remove free radicals:

Superoxide dismutase

Various enzyme systems are available to remove free radicals:

Superoxide dismutase

http://upload.wikimedia.org/wikipedia/commons/9/9a/Antioxidant_pathway.svg


Nitric oxide:Originally called endothelium-derived relaxing factor.

Biological messengerVasodilation

Neurotransmission

Penile erections

Free radical:Not overly reactive

Nitric oxide:Originally called endothelium-derived relaxing factor.

Biological messengerVasodilation

Neurotransmission

Penile erections

Free radical:Not overly reactive


Reactions of NO:

NO + O2- ONOO-

NO + OH NHO2

NO + HbO2 MetHb + O2

Reactions of NO:

NO + O2- ONOO-

NO + OH NHO2

NO + HbO2 MetHb + O2

Nitric Oxide

Nitric Oxide

Nitric Oxide Oxyhemoglobin Methemoglobin

Superoxide ion

Hydroxyl radical Nitrous Acid

Peroxynitrite


NO

DNA deamination

Nitration(Tyr-NO2)

Nitrosylation(Cys-NO)

Soluble guanylyl cyclase

Heme-containing enzymes

Transcription Factors

LOW NO CONCE

NTRATION

HIGH NO CONCE

NTRATION


Oxidative stressDamage from free radicals results from oxidation and free radical attack on living tissues.

Associated with aging:Cardiovascular disease (atherogenesis)

Alzheimer’s disease

Parkinson’s disease

Diabetes

Motor neuron disease

Oxidative stressDamage from free radicals results from oxidation and free radical attack on living tissues.

Associated with aging:Cardiovascular disease (atherogenesis)

Alzheimer’s disease

Parkinson’s disease

Diabetes

Motor neuron disease


CO is actually a two-edged sword.

It possesses some protective effects in some situations.

It possesses some harmful effects in other situations.

CO is actually a two-edged sword.

It possesses some protective effects in some situations.

It possesses some harmful effects in other situations.

Source: Mannaioni PF, Vannacci A, Masini E. “Carbon monoxide: the bad and the good side of the coin, from neuronal death to anti-inflammatory activity.” Inflamm Res. 2005;55:261-273


CO exposure can cause:Increased NO levels

Increased superoxide levels

These can combine to form the highly toxic peroxynitrite.

Effect of free radicals is primarily on the vasculature.

May cause hemorrhagic necrosis.

CO exposure can cause:Increased NO levels

Increased superoxide levels

These can combine to form the highly toxic peroxynitrite.

Effect of free radicals is primarily on the vasculature.

May cause hemorrhagic necrosis.

Source: Ischiropoulos H, et al. “Nitric oxide production and perivascular tyrosine nitration in brain after carbon monoxide poisoning in the rat.” J Clin Invest. 1996;97:2260-2267


CO exposure can cause:Increased hydroxyl radicals noted during both the hypoxic and reoxygenation stage.

CO exposure can cause:Increased hydroxyl radicals noted during both the hypoxic and reoxygenation stage.

Source: Zang J, Piantadosi CA. “Mitochondrial oxidative stress after carbon monoxide hypoxia in the rat brain.” J Clin Invest. 1992;90:1193-1199


Ill Effects:CO causes hypoxia due to:

The direct effect on hemoglobin

Impaired perfusion from cardiac dysfunction.

CO impairs mitochondrial electron transport because CO binds to CcOX (at higher COHb levels).

Impairs brain ATP synthesis.

Ill Effects:CO causes hypoxia due to:

The direct effect on hemoglobin

Impaired perfusion from cardiac dysfunction.

CO impairs mitochondrial electron transport because CO binds to CcOX (at higher COHb levels).

Impairs brain ATP synthesis.

Source: Thom SR, Bhopale VM, Han S-T, Clark JM, Hardy KR. “Intravascular Neutrophil Activation Due to Carbon Monoxide Poisoning.” Am J Respir Crit Care Med. 2006;174:1239-1248


1. CO binds to platelet hemoproteins and increases NO efflux.

2. Platelet-derived NO reacts with neutrophil-derived superoxide which activates platelets and causes platelet-neutrophil aggregates.

3. Reactive products and adhesion molecules promote firm aggregation and stimulate degranulation of neutrophils.

4. Endothelial cells acitaved by myeloperoxidase facilitating firm neutrophil adhesion and further degranulation.

5. Reactive oxygen species (ROS) initiate lipid peroxidation and adducts interact with brain myelin basic protein. The altered myelin basic protein triggers an adaptive immunologic response that causes neurologic dysfunction.


Ill Effects:Increased mitochondrial production of free radicals.

Although energy production and mitochondrial function may be restored after COHb levels fall, neuronal cell death (apoptosis) can still occur.

Ill Effects:Increased mitochondrial production of free radicals.

Although energy production and mitochondrial function may be restored after COHb levels fall, neuronal cell death (apoptosis) can still occur.



COHb levels do not always correspond with symptoms.

Indicates that other factors are involved.

COHb levels do not always correspond with symptoms.

Indicates that other factors are involved.


Impact of CO on major body systems:Cardiac:

Decreased myocardial function:Hypotension with tachycardia.

Chest pain.

Dysrhythmias.

Myocardial ischemia.

Most CO deaths are from ventricular fibrillation.

Long-term effects:Increased risk of premature cardiac death.

Impact of CO on major body systems:Cardiac:

Decreased myocardial function:Hypotension with tachycardia.

Chest pain.

Dysrhythmias.

Myocardial ischemia.

Most CO deaths are from ventricular fibrillation.

Long-term effects:Increased risk of premature cardiac death.


Impact of CO on major body systems:Metabolic:

Respiratory alkalosis (from hyperventilation).Metabolic acidosis with severe exposures.

Respiratory:Pulmonary edema (10-30%)

Direct effect on alveolar membrane.Left-ventricular failure.Aspiration.Neurogenic pulmonary edema.

Impact of CO on major body systems:Metabolic:

Respiratory alkalosis (from hyperventilation).Metabolic acidosis with severe exposures.

Respiratory:Pulmonary edema (10-30%)

Direct effect on alveolar membrane.Left-ventricular failure.Aspiration.Neurogenic pulmonary edema.


Impact of CO on major body systems:Multiple Organ Dysfunction Syndrome (MODS):

Occurs at high-levels of exposure.

Associated with a high mortality rate.

Impact of CO on major body systems:Multiple Organ Dysfunction Syndrome (MODS):

Occurs at high-levels of exposure.

Associated with a high mortality rate.


Delayed Neurologic Syndrome (DNS):Recovery seemingly apparent.Behavioral and neurological deterioration 2-40 days later.True prevalence uncertain (estimate range from 1-47% after CO poisoning).Patients more symptomatic initially appear more apt to develop DNS.More common when there is a loss of consciousness in the acute poisoning.

Delayed Neurologic Syndrome (DNS):Recovery seemingly apparent.Behavioral and neurological deterioration 2-40 days later.True prevalence uncertain (estimate range from 1-47% after CO poisoning).Patients more symptomatic initially appear more apt to develop DNS.More common when there is a loss of consciousness in the acute poisoning.

Delayed Neurologic SyndromeDelayed Neurologic Syndrome

Signs and Symptoms:

Memory loss

Confusion

Ataxia

Seizures

Urinary incontinence

Fecal incontinence

Emotional lability

Signs and Symptoms:

Memory loss

Confusion

Ataxia

Seizures


Fecal incontinence

Emotional lability

Signs and Symptoms:

Disorientation

Hallucinations

Parkinsonism

Mutism

Cortical blindness

Psychosis

Gait disturbances

Other motor disturbances

Signs and Symptoms:

Disorientation

Hallucinations

Parkinsonism

Mutism

Cortical blindness

Psychosis

Gait disturbances

Other motor disturbances

Pathophysiology SummaryPathophysiology Summary

Limits O2 transport:

CO more readily binds to Hb forming COHb.

Inhibits O2 transfer:

CO changes structure of Hb causing premature release of O2 into the tissues.

Tissue inflammation:Poor perfusion initiates an inflammatory response.

Limits O2 transport:

CO more readily binds to Hb forming COHb.

Inhibits O2 transfer:

CO changes structure of Hb causing premature release of O2 into the tissues.

Tissue inflammation:Poor perfusion initiates an inflammatory response.


Poor cardiac function: O2 delivery can cause dysrhythmias and myocardial dysfunction.Long-term cardiac damage reported after single CO exposure.

Increased activation of nitric oxide (NO):

Peripheral vasodilation.Inflammatory response.

Poor cardiac function: O2 delivery can cause dysrhythmias and myocardial dysfunction.Long-term cardiac damage reported after single CO exposure.

Increased activation of nitric oxide (NO):

Peripheral vasodilation.Inflammatory response.


Vasodilation:Results from NO increase.Cerebral vasodilation and systemic hypotension causes reduced cerebral blood flow.NO is largely converted to methemoglobin.

Free radical formation:NO accelerates free radical formation.Endothelial and oxidative brain damage.

Vasodilation:Results from NO increase.Cerebral vasodilation and systemic hypotension causes reduced cerebral blood flow.NO is largely converted to methemoglobin.

Free radical formation:NO accelerates free radical formation.Endothelial and oxidative brain damage.

Patient Groups at RiskPatient Groups at Risk

Children.

Elderly.

Persons with heart disease.

Pregnant women.

Patients with increased oxygen demand.

Patients with decreased oxygen-carrying capacity (i.e., anemias, blood cancers).

Patients with chronic respiratory insufficiency.

Children.

Elderly.

Persons with heart disease.

Pregnant women.

Patients with increased oxygen demand.

Patients with decreased oxygen-carrying capacity (i.e., anemias, blood cancers).

Patients with chronic respiratory insufficiency.

ClinicalClinical

11-year chart review of 1,533 patients admitted to a burn unit.

18 patients with COHb levels 10%.

“These data suggest that myocardial damage can result from acute carbon monoxide poisoning, and appropriate screening is indicated for the detection of such injuries.”

11-year chart review of 1,533 patients admitted to a burn unit.

18 patients with COHb levels 10%.

“These data suggest that myocardial damage can result from acute carbon monoxide poisoning, and appropriate screening is indicated for the detection of such injuries.”

Source: Williams J, Lewis II RW, Kealey GP. ,“Carbon Monoxide Poisoning and Myocardial Ischemia in Patients with Burns.” J Burn Care Rehabil. 1999;12:210-213

ClinicalClinical

12-year boy who suffered occult damage despite mild symptoms and low COHb levels.

COHb at admission was 24.5%.

ECG showed sinus tachycardia with diffuse ST segment elevation.

Heart and valvular abnormalities noted.

No long-term complications

12-year boy who suffered occult damage despite mild symptoms and low COHb levels.

COHb at admission was 24.5%.

ECG showed sinus tachycardia with diffuse ST segment elevation.

Heart and valvular abnormalities noted.

No long-term complications

Source: Gandini C, et al. “Cardiac Damage in Pediatric Carbon Monoxide Poisoning.” Clin Tox. 2001;39:45-510-213

ClinicalClinical

Smoking, CO, and Heart Disease:“Patients under age 65 without symptoms of ischemic heart disease who smoked shortly before surgery had more episodes of rate pressure product-related ST segment depression than nonsmokers, prior smokers, or chronic smokers who did not smoke before surgery.”

Smoking, CO, and Heart Disease:“Patients under age 65 without symptoms of ischemic heart disease who smoked shortly before surgery had more episodes of rate pressure product-related ST segment depression than nonsmokers, prior smokers, or chronic smokers who did not smoke before surgery.”

Source: Woehlck HJ, Connolly LA, Cinquegrani MP, Dunning MB, Hoffman RG. “Acute Smoking Increases ST Depression in Humans During General Anesthesia.” Anesth Analg. 1999;89:856-860

ClinicalClinical

Neurological Complications:Prospective evaluation of 127 CO-poisoned patients.

Depression and anxiety measured at 6-weeks, 6-months, and 12-months.

Neurological Complications:Prospective evaluation of 127 CO-poisoned patients.

Depression and anxiety measured at 6-weeks, 6-months, and 12-months.

Source: Jasper BW, Hopkins RO, Van Duker H, Weaver LK. “Affective Outcome Following Carbon Monoxide Poisoning: A Prospective Longitudinal Study.” Cog Behav Neurol. 2005;18:127-134

ClinicalClinical

Neurological Complications:

Outcomes (anxiety and depression):

6-weeks: 45%

6-months: 44%

12-months: 43%

At 6-weeks people who attempted suicide had a higher prevalence of anxiety and depression.

No differences between groups at 12-months.


Outcomes (anxiety and depression):

6-weeks: 45%

6-months: 44%

12-months: 43%

At 6-weeks people who attempted suicide had a higher prevalence of anxiety and depression.

No differences between groups at 12-months.

Source: Jasper BW, Hopkins RO, Van Duker H, Weaver LK. “Affective Outcome Following Carbon Monoxide Poisoning: A Prospective Longitudinal Study.” Cog Behav Neurol. 2005;18:127-134

ClinicalClinical


Biosphere 2 participant developed atypical Parkinsonism and a gait disturbance after living 2 years in the project.

Findings postulated to be do to chronic hypoxia and CO exposure.


Biosphere 2 participant developed atypical Parkinsonism and a gait disturbance after living 2 years in the project.

Findings postulated to be do to chronic hypoxia and CO exposure.

Source: Lassinger BK, et al. “Atypical Parkinsonism and Motor Neuron Syndrome in a Biosphere 2 Participant: A Possible Complication of Chronic Hypoxia and Carbon Monoxide Toxicity?” Mov Disord. 2004;19:465-469

ClinicalClinical


5-year-old with CO poisoning (COHb = 20.2%) recovered following HBOT.

Developed visual and gait disturbances 2 days later (delayed neurologic syndrome).

MRI findings found in brain.


5-year-old with CO poisoning (COHb = 20.2%) recovered following HBOT.

Developed visual and gait disturbances 2 days later (delayed neurologic syndrome).

MRI findings found in brain.

Source: Kondo A, et al. “Delayed neuropsychiatric syndrome in a child following carbon monoxide poisoning” Brain Develop. 2007;29:174-177

ClinicalClinical

230 consecutive patients treated for moderate to severe CO poisoning in the HBO chamber at Hennepin County Medical Center.

Mean age: 47.2 years (72% males)

56% active tobacco smokers.

Other cardiac risk factors uncommon.

230 consecutive patients treated for moderate to severe CO poisoning in the HBO chamber at Hennepin County Medical Center.

Mean age: 47.2 years (72% males)

56% active tobacco smokers.

Other cardiac risk factors uncommon.

Source: Satran D, Henry CR, Adkinson C, Nicholson CI, Bracha Y, Henry TD. “Cardiovascular manifestations of moderate to severe CO poisoning.” J Am Coll Cardiol. 2005;45:1513-1516

Patient CharacteristicsPatient CharacteristicsParameter Number Percentage

Age (yrs) 47.2 19-91 (average/range)

Men 166 72%

Diabetes 15 7%

Hypertension 52 23%

Active smoker 129 56%

Previous MI 15 7%

Previous revascularization 6 3%

Accidental poisoning 159 59%

Intentional poisoning 91 40%

COHb (%) 33.1 2-65 (average range)

Intubated 116 50%

Pressors required 14 6%

Predictors of Myocardial InjuryPredictors of Myocardial Injury

Finding No Injury Injury RR 95% CI

Men 64.8 84.7 3.01 1.52-5.94

GCS 14 41.7 61.5 2.23 1.27-3.94

Hypertension 18.3 31.3 2.04 1.09-3.82

Previous revascularization 0.7 1.2 1.74 0.11-28.16

Diabetes 5.6 8.4 1.55 0.54-4.45

Previous MI 6.3 7.2 1.16 0.403.38

Age (5 yrs) 44.8* 51.2* 1.12 1.03-1.22

COHb level (10%) 32.7† 33.9† 1.03 0.93-1.14

Current smoker 64 48.2 0.52 0.30-0.91

* = Average

† = Measured percent

ClinicalClinical

Ischemic ECG changes present in 30% of patients.

Cardiac biomarkers (CK-MB, troponin-I) were elevated in 35%.

In-hospital mortality: 5%

Conclusions: “Cardiovascular sequelae of CO poisoning are frequent.”

Ischemic ECG changes present in 30% of patients.

Cardiac biomarkers (CK-MB, troponin-I) were elevated in 35%.

In-hospital mortality: 5%

Conclusions: “Cardiovascular sequelae of CO poisoning are frequent.”

Source: Satran D, Henry CR, Adkinson C, Nicholson CI, Bracha Y, Henry TD. “Cardiovascular manifestations of moderate to severe CO poisoning.” J Am Coll Cardiol. 2005;45:1513-1516

ClinicalClinical

Sartran et al.: “Myocardial injury from CO poisoning results from tissue hypoxia as well as damage at the cellular level.”

“In vitro, CO binds to cytochrome-c oxidase of the electron transport chain resulting in asphyxiation at the cellular level.”

“Oxygen radical formation and subsequent lipid peroxidation has been implicated as a mechanism for cell death.”

“High concentrations of CO have been to induce cellular apoptosis mediated by nitric oxide.”

Sartran et al.: “Myocardial injury from CO poisoning results from tissue hypoxia as well as damage at the cellular level.”

“In vitro, CO binds to cytochrome-c oxidase of the electron transport chain resulting in asphyxiation at the cellular level.”

“Oxygen radical formation and subsequent lipid peroxidation has been implicated as a mechanism for cell death.”

“High concentrations of CO have been to induce cellular apoptosis mediated by nitric oxide.”

ClinicalClinical

230 consecutive patients treated for moderate to severe CO poisoning in the HBO chamber at Hennepin County Medical Center (1/1/94-1/1/02).

Patients followed through 11/11/05.

230 consecutive patients treated for moderate to severe CO poisoning in the HBO chamber at Hennepin County Medical Center (1/1/94-1/1/02).

Patients followed through 11/11/05.

Source: Henry CR, Satran D, Lindgren B, Adkinson C, Nicholson CI, Henry TD. “Myocardial Injury and Long-Term Mortality Following Moderate to Severe Carbon Monoxide Poisoning.” JAMA. 2006;295:398-402

ClinicalClinical


ClinicalClinical

At median follow-up of 7.6 years:54 (24%) deaths [12 (5%) in-hospital]

85 patients sustained myocardial injury from CO poisoning:

32 (38%) eventually died

22 patients did not sustain myocardial injury:22 (15%) eventually died

At median follow-up of 7.6 years:54 (24%) deaths [12 (5%) in-hospital]

85 patients sustained myocardial injury from CO poisoning:

32 (38%) eventually died

22 patients did not sustain myocardial injury:22 (15%) eventually died


ClinicalClinical

“Myocardial injury occurs frequently in patients hospitalized for moderate to severe CO poisoning and is a significant predictor of mortality.”

“Myocardial injury occurs frequently in patients hospitalized for moderate to severe CO poisoning and is a significant predictor of mortality.”


CO PoisoningCO Poisoning

Signs and symptoms usually vague and non-specific.

Signs and symptoms usually vague and non-specific.

You must ALWAYS

maintain a high index of suspicion for

CO poisoning!

CO PoisoningCO Poisoning

Signs and symptoms closely resemble those of other diseases.Often misdiagnosed as:

Viral illness (e.g., the “flu”)Acute coronary syndromeMigraine

Estimated that misdiagnosis may occur in up to 30-50% of CO-exposed patients presenting to the ED.

Signs and symptoms closely resemble those of other diseases.Often misdiagnosed as:

Viral illness (e.g., the “flu”)Acute coronary syndromeMigraine

Estimated that misdiagnosis may occur in up to 30-50% of CO-exposed patients presenting to the ED.Source: Raub JA, Mathieu-Holt M, Hampson NB, Thom SR. Carbon Monoxide Poisoning: A Public Health Perspective. Toxicology 200;145:1-14

Signs and Symptoms (Acute)Signs and Symptoms (Acute)

MalaiseFlu-like symptomsFatigueDyspnea on exertionChest painPalpitationsLethargyConfusionDepression

MalaiseFlu-like symptomsFatigueDyspnea on exertionChest painPalpitationsLethargyConfusionDepression

ImpulsivenessDistractibilityHallucinationConfabulationAgitationNauseaVomitingDiarrheaAbdominal pain

ImpulsivenessDistractibilityHallucinationConfabulationAgitationNauseaVomitingDiarrheaAbdominal pain

Signs and Symptoms (Acute)Signs and Symptoms (Acute)

Headache

Drowsiness

Dizziness

Weakness

Confusion

Visual disturbances

Syncope

Seizures

Headache

Drowsiness

Dizziness

Weakness

Confusion

Visual disturbances

Syncope

Seizures

Fecal incontinence


Memory disturbances

Gait disturbances

Bizarre neurologic symptoms

Coma

Death

Fecal incontinence


Memory disturbances

Gait disturbances

Bizarre neurologic symptoms

Coma

Death

Signs and SymptomsSigns and Symptoms

Severity CO-Hb Level

Signs & Symptoms

Mild < 15 - 20% Headache, nausea, vomiting, dizziness, blurred vision.

Moderate 21 - 40% Confusion, syncope, chest pain, dyspnea, weakness, tachycardia, tachypnea, rhabdomyolysis.

Severe 41 - 59% Palpitations, dysrhythmias, hypotension, myocardial ischemia, cardiac arrest, respiratory arrest, pulmonary edema, seizures, coma.

Fatal > 60% Death

Cherry red skin color is not always

present and, when present, is often a late

finding.

COHb levels do not always

correlate with

symptoms nor predict sequelae.

Carbon Monoxide DetectionCarbon Monoxide Detection

CO detectors have been widely-available for over a decade.

Still vastly underutilized.

Underwriters Laboratories (UL) revised guidelines for CO detectors in 1998.

Units manufactured before 1998 should be replaced.

CO detectors have been widely-available for over a decade.

Still vastly underutilized.

Underwriters Laboratories (UL) revised guidelines for CO detectors in 1998.

Units manufactured before 1998 should be replaced.


Hand-held devices now available to assess atmospheric levels of CO.Multi-gas detectors common in the fire service:

Combustible gassesCO

O2

H2S

Hand-held devices now available to assess atmospheric levels of CO.Multi-gas detectors common in the fire service:

Combustible gassesCO

O2

H2S


Biological detection of CO limited:

Exhaled CO measurement.

Hospital-based carboxyhemoglobin levels (arterial or venous).

Biological detection of CO limited:

Exhaled CO measurement.

Hospital-based carboxyhemoglobin levels (arterial or venous).


Technology now available to detect biological COHb levels in the prehospital and ED setting.Referred to as CO-oximetry

Technology now available to detect biological COHb levels in the prehospital and ED setting.Referred to as CO-oximetry

Carbon Monoxide DetectionCarbon Monoxide DetectionNew generation oximeter/CO-oximeter can detect 4 different hemoglobin forms.

Deoxyhemoglobin (Hb)

Oxyhemoglobin (O2Hb)Carboxyhemoglobin (COHb)Methemoglobin (METHb)

Provides:SpO2

SpCOSpMETPulse rate

New generation oximeter/CO-oximeter can detect 4 different hemoglobin forms.

Deoxyhemoglobin (Hb)

Oxyhemoglobin (O2Hb)Carboxyhemoglobin (COHb)Methemoglobin (METHb)

Provides:SpO2

SpCOSpMETPulse rate

CO-OximetryCO-Oximetry

Uses finger probe similar to that used in pulse oximetry.Uses 8 different wavelengths of light (instead of 2 for pulse oximetry).Readings very closely correlate with COHb levels measured in-hospital.

Uses finger probe similar to that used in pulse oximetry.Uses 8 different wavelengths of light (instead of 2 for pulse oximetry).Readings very closely correlate with COHb levels measured in-hospital.


What is the accuracy?What is the accuracy?


Carboxyhemoglobin (Range of 0-15%): Accuracy 2%

Methemoglobin (Range of 0-12%) Accuracy 0.5%

Carboxyhemoglobin (Range of 0-15%): Accuracy 2%

Methemoglobin (Range of 0-12%) Accuracy 0.5%

Source: Barker SJ, Curry J, Redford D, Morgan S. Measurement of carboxyhemoglobin and methemoglobin levels by pulse oximetry: A human volunteer study. Anesthesiology 2006;105:892-7


Parameter SaO2 (ABL)

SpO2

(RAD 57)SaCO(ABL)

SpCO(RAD 57)

Mean 90.8 5.4 () 93.8 4.2 () 2.0 1.8 () 2.5 2.0 ()

Maximum 97.5 99 9.3 11

Minimum 74.6 80 0.8 1

P Value 0.001 <0.015

Source: Mottram CD, Hanson LJ, Scanlon PD. Comparison of the Masimo RAD57 Pulse Oximeter with SPCO Technology against a Laboratory CO-oximeter Using Arterial Blood. Resp Care. 2005;50:11

Diagnostic CriteriaDiagnostic Criteria

Biologic:COHb > 5% in nonsmokers.

COHb > 10% in smokers.

Environmental:No confirmatory test.

Biologic:COHb > 5% in nonsmokers.

COHb > 10% in smokers.

Environmental:No confirmatory test.

Diagnostic CriteriaDiagnostic Criteria

Suspected:Potentially-exposed person, but no credible threat exists.

Probable:Clinically-compatible case where credible threat exists.

Confirmed:Clinically-compatible case where biological tests have confirmed exposure.

Suspected:Potentially-exposed person, but no credible threat exists.

Probable:Clinically-compatible case where credible threat exists.

Confirmed:Clinically-compatible case where biological tests have confirmed exposure.

TreatmentTreatment

Treatment is based on the severity of symptoms.Treatment generally indicated with SpCO > 10-12%.Be prepared to treat complications (i.e., seizures, dysrhythmias, cardiac ischemia).

Treatment is based on the severity of symptoms.Treatment generally indicated with SpCO > 10-12%.Be prepared to treat complications (i.e., seizures, dysrhythmias, cardiac ischemia).

TreatmentTreatmentAdminister high-concentration oxygen.

Maximizes hemoglobin oxygen saturation.

Can displace some CO from hemoglobin.

Associated with improvements in neurological and cardiac complications.

Administer high-concentration oxygen.

Maximizes hemoglobin oxygen saturation.

Can displace some CO from hemoglobin.

Associated with improvements in neurological and cardiac complications.

The importance of early

administration of high-

concentration oxygen CANNOT

be overemphasized!

TreatmentTreatment

Which is better?Oxygenation

Ventilation

Which is better?Oxygenation

Ventilation

TreatmentTreatment

Prehospital CPAP can maximally saturate hemoglobin and increase oxygen solubility.

Strongly suggested for moderate to severe poisonings.

Prehospital CPAP can maximally saturate hemoglobin and increase oxygen solubility.

Strongly suggested for moderate to severe poisonings.

Source: Jones A, Recent Advances in the Management of Poisoning. Ther Drug Monit 2002;24:150-155

TreatmentTreatment

Efficacy of hyperbaric oxygen therapy (HBO) is a matter of conjecture although still commonly practiced.

Generally reserved for severe poisonings.

May aid in alleviating tissue hypoxia.

Significantly decreases half-life of COHb.

Efficacy of hyperbaric oxygen therapy (HBO) is a matter of conjecture although still commonly practiced.

Generally reserved for severe poisonings.

May aid in alleviating tissue hypoxia.

Significantly decreases half-life of COHb.

Indications for HBO TherapyIndications for HBO Therapy

Strongly consider for:Altered mental status.

Coma.

Focal neurological deficits.

Seizures.

Pregnancy with COHb>15%.

History of LOC.

Strongly consider for:Altered mental status.

Coma.

Focal neurological deficits.

Seizures.

Pregnancy with COHb>15%.

History of LOC.

Indications for HBO TherapyIndications for HBO Therapy

Possibly consider for:Cardiovascular compromise (e.g., ischemia, dysrhythmias).

Metabolic acidosis.

Extremes of age.

Possibly consider for:Cardiovascular compromise (e.g., ischemia, dysrhythmias).

Metabolic acidosis.

Extremes of age.

RememberRemember

Don’t forget about the possibility of cyanide poisoning—alone or with CO!

Don’t forget about the possibility of cyanide poisoning—alone or with CO!

SummarySummary

CO still common and under diagnosed.

There appears to be a link between acute and chronic CO exposure and long term morbidity and mortality.

Effects of CO on hemeproteins and free-radical induction and oxidative stress probable mechanism.

EPs should have a low threshold for screening for CO.

CO still common and under diagnosed.

There appears to be a link between acute and chronic CO exposure and long term morbidity and mortality.

Effects of CO on hemeproteins and free-radical induction and oxidative stress probable mechanism.

EPs should have a low threshold for screening for CO.

carbon monoxide poisoning bryan bledsoe, do, facep

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